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  1. #1
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    The Cholesterol Puzzle

    I've always been a bit puzzled by the cholesterol testing. I've always had questions about the simplicity of the HDL/LDL and Tri's that my doctor gave me. Recently I've mixed up my diet, going mostly carbs with about 20% good protein, and have had good results with the doc's cholesterol equation. But then I ran into the video below. Now I'm questioning some of the common ideas about the status quo. Any idea's or opinions?


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    I will start by saying that I have a significant hereditary lipid issue, so I have read a lot about this subject. (and I still find it confusing as hell!)
    I would like to go back and look up references for some of his claims, and maybe I will, but right now I'll just talk off the top of my head.

    - Regarding your comment on the simplicity of HDL/LDL an triglyceride numbers, you are right it is overly simplistic and the tests he mentions in the video are much better. i have had the VAP and the Berkeley Heart lab tests. I prefer the Berkeley because of the Lp(a) measurement, which surprisingly, he talks about in the video (with some inaccuracy). If you want to know more about your risks, get one of these tests.

    - I do not think he is correct to say that large buoyant LDL particles are not a risk factor. I think they are less of a risk factor.

    - He interpreted his own results as great, but with LDL over 130 and high Lp(a), I would not call them great. He goes so far as to say "now that we know that LDL is not a risk factor..." Not true.

    - I have read about carbs and cholesterol, and his claims are interesting, but I don't think the evidence is as clear as he makes it sound (need to look this up).

    - The evidence that statins reduce risk for CVD is unequivocal. They are fantastic drugs that have extended many lives. I should also note however, that their effectiveness is in part due to reasons other than cholesterol lowering.

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    Quote Originally Posted by smilinsteve View Post
    I will start by saying that I have a significant hereditary lipid issue, so I have read a lot about this subject. (and I still find it confusing as hell!)
    I would like to go back and look up references for some of his claims, and maybe I will, but right now I'll just talk off the top of my head.

    - Regarding your comment on the simplicity of HDL/LDL an triglyceride numbers, you are right it is overly simplistic and the tests he mentions in the video are much better. i have had the VAP and the Berkeley Heart lab tests. I prefer the Berkeley because of the Lp(a) measurement, which surprisingly, he talks about in the video (with some inaccuracy). If you want to know more about your risks, get one of these tests.

    - I do not think he is correct to say that large buoyant LDL particles are not a risk factor. I think they are less of a risk factor.

    - He interpreted his own results as great, but with LDL over 130 and high Lp(a), I would not call them great. He goes so far as to say "now that we know that LDL is not a risk factor..." Not true.

    - I have read about carbs and cholesterol, and his claims are interesting, but I don't think the evidence is as clear as he makes it sound (need to look this up).

    - The evidence that statins reduce risk for CVD is unequivocal. They are fantastic drugs that have extended many lives. I should also note however, that their effectiveness is in part due to reasons other than cholesterol lowering.

    This pretty much sums up the answer to your question, I hope. Smilinsteve did an excellent job; however, if you have any more questions feel free to ask.
    "If you have built castles in the air, that is where they should be. Now put the foundations under them."
    -Thoreau

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    Smilinsteve did do a great job. Thank you Steve.

    Basically, I think we are still learning about inflammation, or cholesterol. I doubt what they are saying in this video is absolutely correct, but I've had similar questions about people having higher cholesterol and lower heart disease, or vice versa. I think we are still behind the learning curve on the cause of inflammation.

    Statins are good drugs but our doctors are prescribing them way too easily. I know this from personal experience. I'm not sure we understand the long term effect of statin use. I'd have a hard time prescribing them to a child like they are doing.

  5. #5
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    Statins significantly reduce adverse events in people with established coronary artery disease, not in the general population.

    The problem with research on cholesterol is that almost all of it assumes that removing saturated and natural fats from the diet and replacing them with artificial and unsaturated fats is good for you when it clearly is not. For the last 5 decades the majority of western world populations have been conned into eating a diet that makes money for the low fat, no fat, polyunsaturated marketers and now you cannot have a control group free of the influence of that dietary pattern. In other words, if you cannot study statins in a group free of this dietary influence, then you cannot say statins make a difference except in those pre-disposed to arterial disease.

    Cholesterol may well be an innocent bystander recruited into an inflammatory process unrelated to lipids, but proving it is not easy even without the need for massive research funding only made available by companies with a vested interest in proving the value of their product - usually pharmaceutical companies.

    The history of modern medicine is one of blurring the boundary between science and outcome. There's been too much minimalism in assessing vascular disease and diet and too many knee jerk reactions that get credence because they sound sensible and can be marketed for profit.

    Fat causes overweight - wrong
    Fat causes vascular disease - wrong
    High cholesterol is dangerous - wrong - it is in some cases, but it is not a universal rule
    The sun causes skin cancer so you shouldn't go in the sun - let's see where that gets us over the next 50 years

    As stated by Michael Pollan in "In Defence of Food" - humans are the only species that has to be told what to eat. Sadly we have been sold a bunch of lies for profit - and we have bought it. Statins cannot fix stupidity.

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    Quote Originally Posted by Ridnparadise View Post
    Statins significantly reduce adverse events in people with established coronary artery disease, not in the general population.

    Not true. Primary prevention data is strong, showing statins improve outcomes of people with no previous history of CVD.

    Here is a good meta analysis saying just that:

    Statins for the primary preventio... [Cochrane Database Syst Rev. 2013] - PubMed - NCBI

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    Quote Originally Posted by smilinsteve View Post
    Not true. Primary prevention data is strong, showing statins improve outcomes of people with no previous history of CVD.

    Here is a good meta analysis saying just that:

    Statins for the primary preventio... [Cochrane Database Syst Rev. 2013] - PubMed - NCBI
    I am very familiar with many of the studies. As I said, (excluding those like yourself who have a hereditary issue) assessing people free of the influence of medically-promoted low fat and reduced saturated fat diets is not possible. Excluding subjects with pre-existing CVD is financially impossible and borderline medically impossible without at least a coronary artery calcium score on every subject. On the ground, those relative risk reductions can amount to an actual benefit of 2 patient adverse events per 100 treated - not a huge benefit.

    There are too many confounding issues with respect to lipids, despite the clear research evidence that there is an association with reducing LDLC and TC and reduced CVD events, regardless of age. There is also too much evidence that before statins and before diet was manipulated for the profit of corporate intermediates (ie: neither producer nor consumer), rates of CVD were lower than they are now with statins.

    Sometimes to get the right answer you have to know what question to ask. The latest US guidelines on lipid management again drop the ball on diet, recommending food choices linked to increasing rates of CVD. The question is why the focus is on lab numbers and pharmaceuticals and not on lifestyle and honest dietary recommendations. For example; the Mediterranean Diet remains the bees knees. No-one mentions that in southern Europe, it and other traditional diets include full-fat dairy, high-fat meats, salamis and other foods preserved with minimal loss of the beast (ie: all the fat, gristle, vessels etc are eaten). The Mediterranean Diet promoted worldwide excludes all food choices we are supposed to avoid - therefore it is fake.

    Perhaps I shouldn't care, because the way things are going no-one will be able to eat a natural diet from birth ever again. I guess it's time to bring on the pills and start them at birth.

  8. #8
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    What qualifications do you have riddeninparadise?

    Sounds a little like conspiracy ......

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    Doctor for 30 years. I am a family or primary care physician in US terms, with a long period of seasonal sports and trauma medicine. My main interest over the last 20 years has been lifestyle medicine (not age extension, aesthetics etc). I prescribe statins every day.

  10. #10
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    Well thankfully you do prescribe statins everyday, because for a moment there your posts read like that was not what you would do.

    Still, being a jack of all trades, usually means you take advice from the specialties, no?

    Saying fat doesn't cause obesity is just glib. Saying cholesterol isn't dangerous is a line I'd expect on popular TV. Sure it isn't per se, but you could equally say high blood pressure isn't dangerous and be equally right and wrong in the context of the receiver

  11. #11
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    Quote Originally Posted by pharmaboy View Post
    Well thankfully you do prescribe statins everyday, because for a moment there your posts read like that was not what you would do.

    Still, being a jack of all trades, usually means you take advice from the specialties, no?

    Saying fat doesn't cause obesity is just glib. Saying cholesterol isn't dangerous is a line I'd expect on popular TV. Sure it isn't per se, but you could equally say high blood pressure isn't dangerous and be equally right and wrong in the context of the receiver
    But I didn't say high BP isn't dangerous did I and I did allow for all points of view in the "receivers". I don't do "glib" in my profession. I did not say fat isn't obesity incarnate, but that eating natural fats is not the cause of obesity in population terms. Popular TV is not the source of my education.

    As far as advice from the specialties goes, the one piece of "specialist" advice I do promote is that when someone changes from zero physical activity to any amount of physical activity, they reduce their cardiorespiratory, diabetes and depression risks by 50%

    Problem with modern medicine is that it recently (last quarter century) responds to what you might call pseudo-science. I get far more pressure from continuous requests to respond to current affairs' program content than I ever feel when interpreting scientific research. What bothers me is that our professional bodies are increasingly responding to public pressure (via lay media). That skews the flow and process of research into what is important in logical population medicine. It influences funding and public promotion. It pollutes science and fact with perceived need.

    I said what I said based on logic and experience with learning. Also, I am half Slovenian (Mediterranean) and half Irish - so I eat right and I don't take ****. Think more before you accuse again please mate.

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    Quote Originally Posted by Ridnparadise View Post
    I said what I said based on logic and experience with learning. Also, I am half Slovenian (Mediterranean) and half Irish - so I eat right and I don't take ****. Think more before you accuse again please mate.
    Wow, is that a veiled threat on the Internet ? ( not that I have any idea what or where the accusation was)

    Logic and learning don't cut it anymore, you need evidence. I am pretty dumb, especially on the ins and outs of CVD. That been the case, I'm prepared to go with the overwhelmingly majority opinion of the cardiologist fraternity - when the ripple against that majority looks like a tide, I'll reconsider my side.

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    Quote Originally Posted by smilinsteve View Post
    - I have read about carbs and cholesterol, and his claims are interesting, but I don't think the evidence is as clear as he makes it sound (need to look this up).
    You can start here:

    Sweden Becomes First Western Nation to Reject Low-fat Diet Dogma in Favor of Low-carb High-fat Nutrition | Health Impact News

    5by5 | Latest in Paleo #88: Is Fat Good?

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    Quote Originally Posted by pharmaboy View Post
    I'm prepared to go with the overwhelmingly majority opinion of the cardiologist fraternity
    That might be a big mistake:

    Lies, Damned Lies, and Medical Science - David H. Freedman - The Atlantic

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  16. #16
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    Quote Originally Posted by pharmaboy View Post
    Wow, is that a veiled threat on the Internet ? ( not that I have any idea what or where the accusation was)

    Logic and learning don't cut it anymore, you need evidence. I am pretty dumb, especially on the ins and outs of CVD. That been the case, I'm prepared to go with the overwhelmingly majority opinion of the cardiologist fraternity - when the ripple against that majority looks like a tide, I'll reconsider my side.
    Veiled threat - come on guy. It was a joke. Somehow I doubt I'll be jumping out of your modem and going psycho.

    You reconsider "your side" whenever you like, but remember that the prime objective of science it to exclude bias and in the case of population medicine, that is not an easy thing to do. Just proving an effect does not mean you have the answer to a health problem. For example, if I told you that I was going to treat your child's meningococcal septicaemia with a drug that offered a relative risk benefit of 0.85 where death was the risk, I suspect you would prefer a drug proven to cure the illness instead.

    Another example from the CVD debate - cardiologists know that raised homocysteine is associated with increased risk, but they don't recommend lowering homocysteine as part of primary care as there is no research evidence that it changes outcomes. Seems a little illogical and it will until a study follows 5-10 year olds through to age 60 with double blind, randomised, lifetime supplements to reduce homocysteine compared to placebo in kids with differing levels of homocysteine. Won't happen though will it - vitamin B sales are already pretty good, so no-one will fund such a huge study and no-one could guarantee that every child and then adult would receive or take their "drugs" daily for life, so the drop-out rate would potentially influence outcomes.

    Small percentages of change do equate to large numbers and that is attractive to bean counters in governments and clearly to companies profiting from statin sales, but it does not address the cause of the CVD epidemic. I initiate and prescribe statins based on evidence in individuals, not populations. I do not recommend removing saturated fats from the diet - never have. I do not recommend lean meat only - no other critter eats only the lean muscle and leaves all the unique proteins and other nutrients that make up everything else in a beast on the ground for the crows. I do not recommend adding artificial fats, but international guidelines do. Is it just me or does eating 500g of margarine laced with plant sterols, Vit D and fish oil per month, instead of 50g of butter make no sense! Low fat dairy - what a crock - it's manipulated food for profit. Even full cream milk is not that now. It used to be 4% fat. Now it is 3.5%

    There is no your and my side here unless it has been created by organisations and institutions chasing profit. Our national Heart Foundations as well as research and pharmaceutical companies have had their snouts in the trough so long on this subject, they don't have a way back without losing face.

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    Sorry, missed the joke entirely....

    But the subject is nonetheless interesting.

    It seems to me there are 2 separate issues here that frequently get tossed into the same pot

    1. Is serum cholesterol (LDL, TG) causal of CVD, and in particular is it predictive of CVD in the otherwise healthy patient.
    2. Are current recommendations for low fat - replacement of - diet reasonably correct.

    I believe one of the problems with evidence for statins is driven by cost of research and timeliness ( as you point out on homocysteine). Each subject enrolled is of similar cost, but results depend on event rates been high. Thus higher risk individuals are chosen in the design to reduce cost. This is at odds with ethical considerations, which demand patients be treated appropriately based on previous studies.

    This greatly restricts the ability to re run trials, leading us towards primary prevention trials with higher risk profiles of events. The lack of primary prevention data for drugs isn't cause for a conspiracy moment, it's simply a problem of cost, numbers and time.

    I can see how presumption of the role of fats and cholesterol in the diet got going following the discovery of serum cholesterol CVD/relationship. Things have changed in this area in the past, eg cholesterol in the diet, the switch to looking at LDL tric and HDL discreetly .

    I do lament however, that medicine doesn't easily realize it's mistakes - no better example, is the complete cessation of HRT following a flawed finding in the nurses study - given my view on that and gynaecologists seeming disregard for re-visiting the topic, perhaps I'm a renegade when I want to be and a democratist when it suits......

    On the plus side, medicine has made extraordinary advances in CVD mortality - this is multi variate - primary care preventative strategies, and interventionist strategies, particularly in the acute setting. The great increase in life expectancy is something to be proud of, inspite of increasing T2 DM and obesity. There is too much negativity in medicine - hell, I suspect that medicine has had a huge role in the reduction of the road toll, yet it is ignored....

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    Quote Originally Posted by smilinsteve View Post
    This is a good article on the subject from Scientifc American, a very credible source:
    Carbs against Cardio: More Evidence that Refined Carbohydrates, not Fats, Threaten the Heart: Scientific American
    Thx SS, quite liked that article - even just had my morning latte sans sugar !

    Edit - the big confounder seems to be T2DM - are they one and the same, and is refined sugar additives masking the true results of fat modifed diets.

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    Quote Originally Posted by Ridnparadise View Post
    Fat causes overweight - wrong
    Fat causes vascular disease - wrong
    High cholesterol is dangerous - wrong - it is in some cases, but it is not a universal rule
    I agree with this whole heartedly and I'm living proof. I was what I considered 60lbs overweight and had some of the worst blood tests imaginable. This was 4 years ago. Once I dropped grains, starch, sugar, processed food, started taking REAL fish oil, and started working out, my life changed dramatically. I eat lot of fat, good fat, my last blood tests were shocking, I've got a severely decreased level of inflammation in every aspect, and in the best shape of my life. I try to eat only 100% grassfed beef, take 10g of FO every morning, and workout(CrossFit + MTB) 3-5x a week. The only supplements I take are pre and post workout shakes and the whey is derive from 100% grassfed free range cows, hormone & antibiotic free, plus they use cherry powder (lower on the glycemic index) as a sweetener. Sugar induces the release of insulin. High periods of insulin cause inflammation, fat storage, fatty streaking in muscles and accelerate arterial diseases. Compare a grain fed(corn) and grassfed steak. The fatty streaking is almost nonexistent in the grassfed. Plus the fat is loaded with omega-3 EPA/DHA. I'm also a huge fan of the Zone Diet as a way to control inflammation and keep you body consistent but it's a hell of a lot of work. Dr. Barry Sears the creator has done some extensive studies on inflammation and control cortisol levels.

  20. #20
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    I eat High-Carb low fat Vegan, and do not have to supplement my diet nor do I need to use caffeine to make it through the day. I agree that processed food and nuts and oils are good fats, but the animal sources of fat and protein are the true causes of all the diseases and problems we face today. Check out the China Study, or read some of Neal Barnards books on preventing and reversing heart disease.

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    Quote Originally Posted by Joshua_B View Post
    I eat High-Carb low fat Vegan, and do not have to supplement my diet nor do I need to use caffeine to make it through the day. I agree that processed food and nuts and oils are good fats, but the animal sources of fat and protein are the true causes of all the diseases and problems we face today. Check out the China Study, or read some of Neal Barnards books on preventing and reversing heart disease.
    Bull$hit. Your method of eating is a diet, whilst eating everything available is healthy eating. The "evidence" against animal products is a crock, delivering research and marketing profit based on presumptions that pollute the entire food industry.

    The true causes of all diseases and problems we face today is us; the human population. At least we can rely on blind evolutionary loops like you vegans to clear the way for the rest of us.

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    Quote Originally Posted by Ridnparadise View Post
    Bull$hit. Your method of eating is a diet, whilst eating everything available is healthy eating. The "evidence" against animal products is a crock, delivering research and marketing profit based on presumptions that pollute the entire food industry.

    The true causes of all diseases and problems we face today is us; the human population. At least we can rely on blind evolutionary loops like you vegans to clear the way for the rest of us.
    Here's a concept for you: You can disagree with someone, without being a dick. Ponder that.

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    Quote Originally Posted by Joshua_B View Post
    I eat High-Carb low fat Vegan, and do not have to supplement my diet nor do I need to use caffeine to make it through the day. I agree that processed food and nuts and oils are good fats, but the animal sources of fat and protein are the true causes of all the diseases and problems we face today. Check out the China Study, or read some of Neal Barnards books on preventing and reversing heart disease.
    Rest in peace, China Study

  24. #24
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    Quote Originally Posted by smilinsteve View Post
    Here's a concept for you: You can disagree with someone, without being a dick. Ponder that.
    No kidding. Now I've learned something on the interweb! From my continuing dickness, you may presume I meant what I said. If someone is stupid enough to blame animal consumption on all our health problems, then let me explain more clearly:

    Firstly - Humans are omnivores. Without the consumption of animal products we would not exist. We would be monkeys in the forest.

    Secondly - without the consumption of animal products, the vegan I offended would not exist.

    Bull$hit is bull$hit. Don't attach your emotions to my comments, thanks.

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    Your the one getting emotional not me, I never said anything against you, I am sorry for my existence, and my opinions Oh mighty one.

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